Upper Extremity Fractures And Dislocations

1. Upper Extremity Fractures And Dislocations Re-written by: Daniel Habashi

2. Shoulder Girdle • Clavicle • Scapula • Humerus

3. Clavicle- Mechanism of Injury • There is no correlation between the fracture location and the mechanism of injury • Falls onto the affected shoulder 87% • Direct impact 7% • Falls onto an outstretched hand 6%

4. Clavicle – clinical evaluation • Arm adducted across the chest and supported by the contra lateral hand • Neurovascular examination • Tenting the skin • Crepitus • X-ray

5. Clavicle – non operative treatment • Reduction if needed • Closed treatment is successful in most cases • Dessaulte cast • Figure-of-eight cast • 4-6 weeks

6. Clavicle – operative treatment • Open fractures • Fractures with associated neurovascular injury • Fractures with severe associated injuries (flail chest with multiple rib fractures) • Cosmetic reasons

7. Clavicle – fixation • Plate • Intramedullary devices (pins) • Cerclage suturing or wiring • External fixation

8. Acromioclavicular joint – mechanism of injury • Most often in the Spring • Fall onto the shoulder with the arm adducted • Fall onto an outstretched hand with force transmission up the arm

9. AC joint – clinical evaluation • Step-off deformity • Possible tenting of the skin overlying the distal clavicle • Limited range of motion • Tenderness • X-ray

10. AC joint – classification • Type I – sprain of the AC ligament • Type II – tear of the AC ligament and sprain of the caracoclavicular ligament • Type III – AC and coracoclavicular ligaments torn with AV joint dislocation

11. AC joint – non-operative treatment • Type I - Rest 10 days, ice packs and sling • Type II – Sling for 2 weeks, gentle range of motion, refrain from heavy activity for 6 weeks • Type III – Sling, early range of motion, acceptance of deformity

12. AC joint – operative treatment • Controversial patients • Heavy laborers, patients 20-25 years of age • Open reduction and suturing

13. Sternoclavicular joint – mechanism of injury • Direct hit • Indirect force applied from antero-lateral or postero-lateral aspects of the shoulder

14. SC joint – classification • Anterior dislocation – more common • Posterior dislocation

15. SC joint – clinical evaluation • Patient supports the affected extremity across the trunk with the contra-lateral arm • Swelling, tenderness, painful range of motion • X-ray

16. SC joint – treatment • Mild sprain – ice packs, sling for 7 days • Moderate sprain or subluxation – ice packs and sling for 4-6 weeks

17. Scapula – mechanism of injury • Relatively uncommon injury • Result of high energy trauma • Suspicion of associated injuries • Fractured ribs • Clavicle • Sternum • Pneumothorax • Pulmonary contusion • Spinal column fractures

18. Scapula – Clinical Evaluation • Full trauma evaluation • Upper extremity supported by the contra-lateral hand • Swelling of the posterior thorax • X-ray

19. Scapula – treatment • Most scapula fractures are treated non-operatively • Sling and early range of motion

20. Proximal humerus – mechanism of injury • A fall onto an outstretched upper extremity from standing height (typically seen in an elderly osteoporotic woman) • High energy trauma (motor vehicle accident) • Direct trauma • Pathologic processes

21. proximal humerus - clinical evaluation • Upper extremity supported by the contralateral hand • Pain, swelling, tenderness, painful range of motion • Crepitus, instability, ecchymosis • X-ray

22. Proximal humerus – clinical evaluation • A careful neurovascular evaluation is required

23. Proximal humerus – treatment • Open reduction and internal fixation (plates, screws, K-wires, pins, flexible nails with tension band) • Prosthetic replacement

24. Humeral shaft – mechanism of injury • Direct trauma (most common) • Indirect: fall on an outstretched arm

25. Humeral shaft – radial nerve injury • Radial nerve injury is something we must take care of • Symptoms of a radial nerve injury is: • dropped hand since it’s responsible for the innervations of all the extensors

26. Humeral shaft – clinical evaluation • Pain, swelling, deformity, shortening of the affected arm • Instability with crepitus • A careful neurovascular exam with special attention to the radial nerve function • X-ray

27. Humeral shaft – non operative treatment • Most humeral shaft fractures will heal with nonsurgical treatment • A hanging cast • A co-aptation splint • Thoracobrachial immobilization (Dessaulte, Velpau dressing)

28. Humeral shaft – operative treatment • Open reduction and internal fixation (plates, screws, intramedullar nails) • External fixation  quite quitequite rare

29. Humeral shaft – radial nerve injury • Most common with middle third fractures • Generally neuropraxia or axonotmesis (function returns within 3-4 months) • Laceration most common in gunshot injuries etc

30. Distal humerus – classification • Supracondylar • Transcondylar • Intercondylar (most common) • Condylar • Capitellum • Etc

31. Distal humerus – mechanism of injury • Fall on outstretched hand with or without an abduction or adduction force (supra and transcondylar fractures) • Force directed against the posterior aspect of an elbox flexed more than 90 degrees

32. Distal humerus – clinical evaluation • Swelling, painful range of motion, crepitus, instability • Elbow held in the flexed position • A careful neurovascular evaluation is essential because the sharp fractured end….

33. Distal humerus – treatment • Open reduction and internal fixation (screws, plates) • Total elbow arthroplasty

34. Glenohumeral dislocation • The shoulder is the most commonly dislocated joint of the body (45% of dislocations)

35. Glenohumeral dislocation – classification • Anterior (most common – 84%) • Posterior ( the second most common - 10%) • Inferior (rare) • Superior (rare)

36. Glenohumeral dislocation – mechanism of injury

37. Glenohumeral dislocation – clinical evaluation • Determine the nature of the trauma • Position of the affected extremity • Painful shoulder, muscular spasm • Neurovascular examination • X-ray